Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Nurse staffing levels are still not safe

BMJ 2016; 353 doi: (Published 13 May 2016) Cite this as: BMJ 2016;353:i2665
  1. David Oliver,
  2. consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}

Setting out his vision to make the NHS “the safest in the world,” Jeremy Hunt has discussed the need for a less bureaucratic, more people centred system using data.1 But endless bureaucratic flip-flopping and political meddling over safe nurse staffing levels illustrate the emptiness of his rhetoric.

In the final 2013 report of his public inquiry into Mid Staffordshire Hospital,2 Robert Francis specifically recommended that “minimum safe staffing and skill-mix levels should be drawn up by the National Institute for Clinical Excellence [NICE] and policed by the Care Quality Commission [CQC].”3

In 2013 the Department of Health evaded this.4 After pressure in professional publications,5 it reluctantly agreed to commission NICE,6 which works independently of government and issues statutory and credible guidelines.

Safe nurse staffing was a concern before Francis and beyond England. For instance, the Royal College of Nursing had produced evidence reviews and recommendations.7 8 The Safe Staffing Alliance has campaigned tirelessly.9 The Welsh Assembly has a safe staffing bill.10 NICE had a body of academic research to call on, and the University of Southampton reported a detailed systematic review.11 This analysed links between patient outcomes, care processes, nurse staffing, and skill mix in 35 primary studies, with clear associations demonstrated.

Then NHS England subverted NICE’s traditional independence by effectively stopping its work, getting its chief nurse to defend the decision to her peers.12 This was driven by fear that a national “formula” might prove unaffordable and inflate costs, but this wasn’t explicitly acknowledged.

Meanwhile, the CQC was on the case, criticising many hospitals for inadequate nurse to patient ratios. No need for an army of inspectors to tell it that nine in 10 establishments are short of their own target that was driven by post-Francis transparency and safety.13

Now NHS England has belatedly acknowledged, only after invocation of the Freedom of Information Act, the true scale of the nursing workforce crisis that ministers previously played down.14 15

Another information request in 2015, integrity, and courage from NICE’s non-executive directors, led to the Health Service Journal releasing the staffing guidelines for settings including emergency departments and mental health being drawn up before they were killed off.

Most recently, the chief nurse of the new oversight body, NHS Improvement, told local services to use local discretion over the safe staffing evidence after all—which is where this story started.16 17 The chief nurse also pushed the highly contentious suggested metric of “care hours per patient day.”18 The same body has told hospitals to reduce head count and cap agency spending,19 which will hardly help nurse to patient ratios.

Confusing, isn’t it. How’s that vision working out, Mr Hunt?



View Abstract